Barbara Starfield, a seminal figure in the health services research community who made landmark contributions in primary care and other areas, died suddenly on Friday, June 10, of an apparent heart attack.

Health Affairs extends its deepest sympathies to the family and friends of Dr. Starfield. To help honor Dr. Starfield’s career, Health Affairs is providing free access until June 28 to the full texts of the articles she has authored and coauthored in the journal, discussed below.

Starfield was a Distinguished Professor in the Departments of Health Policy and Management and Pediatrics at the Johns Hopkins University Schools of Public Health and Medicine. She was also Director of the Johns Hopkins University Primary Care Policy Center. Starfield, a member of the Institute of Medicine, was the author of two landmark books regarding primary care: Primary Care: Concept, Evaluation, and Policy and Primary Care: Balancing Health Needs, Services, and Technology. She was the recipient of numerous awards and honors.

Among the major thrusts of Starfield’s work were health equity and the impact of health services on health, in particular the relative roles of primary and specialty care. She played important roles in the development of major methodological tools, including the Primary Care Assessment Tool, the CHIP tools (to assess adolescent and child health status), and the Johns Hopkins Adjusted Clinical Groups (ACGs) for the assessment of morbidity.

Differences in health—both overall and regarding social disparities—in two countries that are otherwise quite similar [Canada and the United States] are attributed to the important effect of two related phenomena: achievement of important health-system characteristics and a strong clinical primary care infrastructure in Canada. Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services.

The United States achieves none of these characteristics, Starfield noted, while Canada achieves all three.

A new primary care charter. In the July/August 2009 issue of Health Affairs, Starfield joined with Lewis Sandy, Thomas Bodenheimer, and L. Gregory Pawlson to call for a new “Charter for Primary Care” – a multifaceted effort to reverse the decades-long decline in primary care in the United States and the resulting disparity in health and health care between this country and other developed nations. The new charter would focus on five areas, the authors said: improving primary care reimbursement; rebalancing the clinical workforce so that 50 percent of patient care clinicians were practicing primary care; reforming medical education; providing federal government aid to help build primary care capacity in the areas of access, quality improvement, technology support, coordination of care, cost control, and population management; and the tracking of key health care performance measures, including the volume and proportion of visits to specialists.

The impact of specialty care. In a March 15, 2005, online article, Starfield, Leiyu Shi, Atul Grover, and James Macinko found that counties with more primary care physicians had lower mortality rates, but this was not the case for specialist supply. Increasing the supply of specialists will not improve the United States’ position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes, the authors concluded. They suggested that adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Why American children aren’t healthier. Finally, in the September/October 2004 issue of Health Affairs, Starfield argued that this nation’s underdeveloped primary care system was one of the significant reasons why the health status of American children lagged behind the health status of children in other developed countries. She suggested a number of remedies:

(1) Assure that every child has a source of good primary care, through national quality guidelines for such care, disseminated widely to the public and based on characteristics of primary care that are known to be effective; through incentives for family physicians and generalist pediatricians to locate in underserved areas or disincentives to locate in areas with an already adequate physician supply; and through expansion of the program to locate federally qualified CHCs in shortage areas. (2) Eliminate copayments and other forms of cost sharing for primary care. (3) Establish disincentives for the seeking of care directly from specialists by, for example, paying specialists a lower fee if a patient is seen without a referral from primary care. (4) Incorporate primary care assessment in all quality assurance activities. (5) Assure federal and state support for increased training of primary care practitioners. (6) Consistent with the recommendations of the 2004 NRC/IOM report, develop information systems that monitor health and professional activities and that incorporate mechanisms to detect systematic differences across population subgroups defined socially, demographically, and geographically.

Barbara Starfield’s work greatly influenced my view of primary care and its importance in our health care system. I say this as an orthopedist. She was a woman whom I always wanted to meet. Her research and writing were of the highest quality. What a voice is lost. James Rickert, MD

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